Presentation
An elderly lady presented with history of chronic neck pain sudden painless loss of vision.
Patient Data
Altered marrow signal (hyperintense onT2W and hypointense on T1W images) is seen C1 and C2 vertebrae with erosion of cortex. There is apprximately 15 mm cranial migration of dens and is compressing medulla causing white matter edema. There is right side rotation of upper cervical spine. Transverse ligament, atalnto-occipital ligament, and antlanto-axial ligaments are obscured, possible ruptured.
Extensive soft tissue thickening is seen in pre and paravertebral spaces at 1st and 2nd levels.
Incidentally T1 hyperintense 'V' or crescent shaped fluid collection is noted in the subretinal space.This is diagnostic of blood.The apex of the V is attached to the optic disc and the limbs are attached anteriorly to the ora serrata.
Unfortunately CT quality was poor due to technical issues. Approximately 15 mm cranial migration of dens was noted.There is right side rotation of upper cervical spine raising possibility of rupture of transverse ligament , atalnto-occipital ligament, and antlanto-axial ligaments .
Case Discussion
The cranial migration of dens is suggestive of basilar impression. It is seen compressing the medulla resulting in significant white matter edema.This is mainly seen in cases of hyperparathyroidism , rheumatoid arthritis or rickets.
When a detailed history was obtained and clinical examination was done the patient had multiple bone deformities in the hand and also had a history of early morning stiffness.This raised a suspicion of rheumatoid arthritis. She was tested for RA factor which was positive.
Incidentally noted was retinal detachment in left which was the cause of sudden painless loss of vision.
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